A nurse is caring for an infant who is dehydrated and requires IV therapy. The nurse should monitor the infant's response to therapy by performing which of the following actions?
Taking the infant's vital signs every 2 hr
Counting the number of wet diapers every shift
Weighing the infant at the same time every day
Measuring the infant's head circumference twice per day
The Correct Answer is C
A. Taking the infant's vital signs every 2 hr: Monitoring vital signs every 2 hours can help assess the infant’s general condition and detect changes in heart rate and blood pressure, which can indicate changes in hydration status. However, it might not be sufficient alone to monitor fluid status.
B. Counting the number of wet diapers every shift: Tracking the number of wet diapers is an effective way to monitor the infant's fluid output and hydration status. An increase in wet diapers typically indicates improved hydration. This is a practical and non-invasive method for assessing the effectiveness of IV therapy in infants.
C. Weighing the infant at the same time every day: Daily weights are a critical measure of fluid balance in infants. A consistent daily weight check provides a direct and accurate assessment of the infant’s hydration status and response to IV therapy.
D. Measuring the infant's head circumference twice per day: Measuring head circumference is not relevant for monitoring hydration status. It is typically used to assess growth and development in infants, not fluid balance or response to IV therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I'll give him acetaminophen for the pain.": Acetaminophen is used for pain relief and fever reduction but does not address disease transmission. It does not prevent the spread of the streptococcal infection.
B. "I'll discard his toothbrush and buy another.": This is crucial because the streptococcal bacteria can remain on the toothbrush, leading to potential reinfection or spreading the bacteria to others. Replacing the toothbrush after starting antibiotics helps to reduce the risk of reinfection.
C. "I'll continue to encourage him to drink lots of fluids.": Staying hydrated is important for recovery, but it does not prevent the transmission of the infection.
D. "I'll take his temperature every 4 hours.": Monitoring temperature helps track the child’s condition but does not prevent the spread of the infection.
Correct Answer is A
Explanation
A. "Bend forward from the waist with your head and arms downward." This position, known as the Adam’s forward bend test, is commonly used to screen for scoliosis. It allows the nurse to observe for any asymmetry in the rib cage or spine, which could indicate scoliosis.
B. "Lie prone on the examination table." Lying prone (face down) does not allow for the assessment of spinal curvature or rib asymmetry. This position is not useful for scoliosis screening.
C. "Touch your chin to your chest, and then look up at the ceiling." These movements assess neck flexibility and range of motion, which are not relevant for screening scoliosis.
D. "Turn to the side, and remain in a relaxed position." Turning to the side and relaxing does not provide the necessary view of the spine to assess for scoliosis. This position does not allow for a clear view of any asymmetry in the spine or ribs.
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